Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the status of three residents. For one resident with diagnoses including anemia and paraplegia, the MDS indicated anticoagulant use during the 7-day look-back period, but the clinical record did not contain a physician order for any anticoagulant medication. This was confirmed as a coding error by the Registered Nurse Assessment Coordinator. Another resident, with diagnoses of epilepsy, diabetes mellitus, and major depressive disorder, was admitted to hospice services per physician order, but the MDS assessment did not reflect hospice care during the 14-day assessment period. The Licensed Practical Nurse Assessment Coordinator acknowledged this as an entry error. A third resident, diagnosed with anemia and hemiplegia, had their MDS coded to indicate daily use of a physical restraint (chair prevents rising), but the clinical record lacked any physician order or assessment for restraint use. The Director of Nursing stated that the facility is restraint-free and believed the resident used a regular wheelchair. The LPN Assessment Coordinator confirmed the MDS was incorrectly coded for restraint use. The Nursing Home Administrator and Director of Nursing confirmed that the MDS assessments for these three residents did not accurately reflect their status.